Vascular and Non Vascular Interventional Radiology

Tiny tubes (catheters), wires, balloons, coils, glue, plastic particles—these sound like the pieces of a child’s construction kit, but these are our tools of a rapidly growing branch of medicine. Further, all imaging machines are at the disposal of the interventional radiologist, whose knowledge of the unique advantages and limitations of each modality allows him/her to efficiently perform safe and effective procedures.

A. Non-Vascular Procedures

• Drain insertions: At one time, surgery was required for people who required a tube to drain a fluid collection, but today these procedures can be done without surgery by an interventional radiologist. He can place a tube through the skin into different parts of the body to drain fluids. E.g. in urine obstruction because of stones, and in biliary system for obstructive jaundice. A suitable stent if necessary may be placed a few days after the drainage to help hold open the obstruction in natural tract so as to drain the fluid inside the body.

• Radiofrequency ablation (RF/RFA): This involves a localized destruction of tissue by heating by special needles. It can be performed in cancer like HCC etc. , bone tumor like osteoid osteoma etc. This treatment is very effective for osteoid osteoma with immediate relief of symptoms

• Fallopian Tube recanalisation (Female Infertility): In 36% of infertile females, fallopian tubes are seen to be occluded at their proximal ends. This can be because of spasm, intraluminal debris, or fibrosis at the cornua. In the past, remedy to this situation included tubal microsurgery or in vitro fertilization. However these have a variable success rate and are expensive procedures. Interventional radiologist provides another alternative. With standard catheters and guide wires, the fallopian tubes are catheterized and the debris is cleared. This 15-minute procedure achieves recanalisation in 90% of patients and a pregnancy rate is 33% to 50%.

Interventional Radiology in Pain Management:

• Vertebroplasty: This is an image-guided nonsurgical therapy, involves percutaneous injection of biocompatible bone cement inside fractured/compressed vertebrae (spinal bone), to strengthen a vertebra that has been weakened by osteoporosis or, less commonly, cancer. It is usually successful at alleviating the pain caused by a compression fracture. It can prevent further vertebral collapse, increase the patient functional abilities, and allow a return to the previous level of activity.

• Ozone treatment: This is relatively a new treatment where freshly prepared ozone gas is injected into the spine. It is used for disc herniation and patient is relived of pain.

B. Vascular Procedures (Establishing Flow). Interventional Radiologist are vascular experts and offer various following procedures:

• Diagnostic Angiography: It is a method of imaging the blood vessels to look for abnormalities, in which a contrast agent (dye) is injected into the blood stream and followed by x-ray. Areas of abnormalities/blockage can easily be seen.

• Balloon angioplasty/stent: A balloon-tipped catheter is taken to the site of a narrow or blocked vessel and balloon is inflated to open the vessel so as to improve the blood flow. The balloon is then deflated and removed from the vessel. Vascular stenting, often performed at the same time as an angioplasty, involves the placement of a small wire mesh tube called a stent in the newly opened artery.. This procedure is done for various arteries or veins anywhere in the body, may be in brain or in legs. Few examples are shown below:
• Peripheral Arterial Disease: Following is example of young smoker with blackening of both legs.
• Renal Hypertension: If stenosis of renal artery is causing the increase in blood pressure, this can also be treated by balloon and/or stents.
• Budd Chairi Syndrome: There is complete occlusion of IVC due to membrane. In following example membranotomy and stenting was performed successfully by minimal invasive technique.
• Transient Ischemic Attack: Carotid Angioplasty/Stenting is a safe alternative to carotid endarterectomy in the small percentage of patients who are thought to have a stroke as a result of carotid stenosis.

• Endograft repair of arterial aneurysms – An aneurysm is a weakening in the wall of an artery causing its abnormal dilatation or leaking of blood. An endograft repair is a non-surgical technique to treat the arterial aneurysm while maintaining the antegrade flow in the affected vessel. An endograft (a fabric tube) is taken through the catheter to the site of the aneurysm, where it is expanded, reinforcing the vessel and thus establishing the normal pathway for the blood.

• Intrarterial Thrombolysis: Most ischemic cerebral strokes are caused by thromboembolic occlusion of brain vessels. Intrarterial thrombolysis is a method of delivering clot dissolving drugs (like Urokinsae) directly into the body of the embolus to lyse it and thus permit reperfusion of ischemic brain tissue. As compared to systemic thrombolysis, the risk of intracranial hemorrhage is significantly less with local thrombolysis. Similarly insitu thrombolysis can be performed for pulmonary emboli, leg vein thrombi, superior saggital sinus, thrombosed hemodialysis accesses etc with both drugs and mechanical means.

• Venous access: This involves insertion and management of specialized kinds of intravenous devices (IVs) (e.g. PICC lines, Hickman lines, subcutaneous ports) for administering long or short-term medications.

• Dialysis access/intervention: It means establishing and maintaining vascular access (site on the body where blood is removed and returned), for hemodialysis patients. Further IR can do the revision/thrombolysis of poorly functioning surgically placed AV fistulas and grafts.

• TIPS (Transjugular Intrahepatic Porto-systemic Shunt): In select patients with complications of severe liver diseases and portal hypertension, uncontrolled by medical treatment, Transjugular Intrahepatic Porto-systemic Shunt (TIPS) as a less-invasive alternative to surgery is very effective treatment.

C. Vascular Procedures (Occluding Flow) and Others

• Embolization: It means therapeutic and purposeful occlusion of blood vessels by various embolic agents including gelfoam alcohol, glue, metallic coils, polyvinyl alcohol particles, Embospheres etc. Few of the indications are
  • Blocking abnormal blood (artery) vessels/aneurysms (e.g., for the purpose of stopping bleeding), as Gastrointestinal Bleed or intracerebral bleed due to rupture of intracranial Aneurysms.
  • Blocking normal arteries of organs to stop the extra function e.g. Embolisation of the spleen for hypersplenism.
  • Blocking vessels of organs to stimulate their hypertrophy e.g. portal vein embolisation (PVE): In hepatoma, inadequate remnant liver volume is the major cause of postoperative liver failure. PVE is a safe and effective method for inducing selective hepatic hypertrophy of the non diseased portion of the liver and may thereby reduce complications and shorten hospital stays after resection.
  • Uterine artery embolisation (UAE) for uterine fibroids. Although hysterectomy and myomectomy are common treatment for symptomatic fibroids, UAE is uterus saving, non surgical and less risky good alternative treatment option to women with symptomatic fibroids or who wish to remain fertile and avoid surgery.
  • Preoperative embolisation: Hyper vascular Tumors like nasopharyngeal angiofibroma, renal carcinomas can be embolised preoperatively to minimize introperative bleeding which provides clearer operative view. Also the need of blood transfusion is reduced
  • Arteriovenous malformations/Hemangioma: These are quite common disorders associated with significant morbidity. Pre-operative embolisation may be performed to reduce the nidus flow as much as possible. In many cases intraarterial or direct sclerotherapy/embolisation is the best option to treat such lesions.
  • Male Infertility: A varicocele is variably considered the commonest ‘correctable’ cause of male infertility. Surgical ligation is the standard treatment however varicocele embolization, is a most unutilised. non surgical treatment. It is safe and more effective outpatient procedure with low recurrence rate as compared to surgery.

• Chemoembolization: It means delivering cancer treatment (medicines) directly to a tumor through its blood supply. Clot-inducing substances are then used to block the artery, ensuring that the delivered chemotherapy is not “washed out” by continued blood flow. This is generally done on an outpatient basis and requires only sedation, not general anesthesia. As compared to systemic chemotherapy adverse effects are less with this kind of treatment as these drugs as given to the cancer directly instead of to whole body.

• Endovenous laser ablation of varicose veins: This is non-surgical treatment of venous insufficiency. IR places a laser fiber inside the vein and then sends out laser (or radiofrequency) energy that shrinks and seals the vein wall, and thus symptoms from the varicose vein improve. The normal healthy veins around the closed vein restore the normal flow of blood.

• IVC filters: IVC stands for inferior vena cava, a major blood vessel that returns blood from the lower body to the heart. Pulmonary embolism is potentially lethal but can be avoided by prompt diagnosis and treatment of deep venous thrombosis (clot in leg veins). The standard therapy is anticoagulation. However, inferior vena cava filter placement is indicated when anticoagulants are contraindicated or have failed. An IVC filter is a small piece of metal that can be put into the IVC to prevent blood clots in the legs from going up to the lungs so as to prevent complications like lung damage.

• Biopsy: It is taking of a tissue sample from the area of interest for pathological examination.. Transjugular liver biopsy: This is an alternative to percutaneous biopsy in patients with diffuse liver disease with massive ascites or serious coagulopathy. The main advantage is that the liver tissue is obtained within the vascular system, rather than directly through the skin into the liver thereby minimizing the risk of bleeding. It takes about 30 and 60 minutes.

• Intravascular foreign body retrieval: With minimal invasive and non-surgical technique and with help of delicate and dedicated instruments, IR can remove the foreign body like broken pieces of catheters etc., from the arteries or veins.

• Will IR treatment hurt?  There can be some discomfort. Local anesthetic (numbing medicine) or sedation is used as needed for pain and anxiety. Often you will feel warmth from the dye.
• For how much time will I be required to stay in the hospital?  It depends on the kind of procedure. For diagnostic Angiography, you will be needed to stay in hospital for 6 hours after the procedure is over
  Some therapeutic procedures are performed on outpatient basis, and you can go home same day, however for other procedures like embolization and stenting, 1 to 3 days hospital stay is required.
• Is this treatment costly?  The materials used for these procedures are expensive and more or less all these are imported from foreign countries. So at the beginning, the interventional procedures are sometimes expensive than surgery or other alternatives. However with IR procedures large incision is not needed, so hospital stay is either not required or reduced, patient can soon start his normal day to day activities and go back to earn his livelihood. Further expensive medicines are often not needed. So taking all these into account, IR procedures are less expensive
• Are there any Limitations/disadvantages of this treatment option? Why these treatment options are not available very commonly?  These are highly sophisticated medical procedures performed by skilled radiologists under the guidance of very expensive machines. Therefore these treatments are operator dependent and require state of the art machines for good resolution so as to help the IR to reach the diseased part as near as possible. Further to a certain extent, these treatments are anatomy dependent and so sometimes it becomes difficult for IR to reach superselctively and offer suitable treatment.

Interventional radiologist work closely with other physicians and aims to cure, or stabilize symptoms due to vascular (related to blood vessels) and non vascular lesions in the various organs of the body. A brief list of procedures includes the following:

Paras Hospital, Gurgaon has an experienced team and sophisticated technology to offer these skilled procedures.

To know more about the interventional radiologists, cost or estimate of interventional radiology and how radiology can help detect and diagnose disease, please share your request and reports at contact@parashospitals.com